Primary Nursing Diagnosis

Ineffective airway clearance related to hypoventilation or airway obstruction.

OUTCOMES. Respiratory status: Gas exchanges; Respiratory status: Ventilation; Comfort level

INTERVENTIONS. Airway management; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Anxiety reduction; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring

290 Diffuse Axonal Injury


Endotracheal intubation and mechanical ventilation are critical to ensure oxygenation and ventilation and to decrease the risk of pulmonary aspiration. A PaO2 greater than 100 mm Hg and a PaCO2 between 28 and 33 mm Hg may be maintained to decrease cerebral blood flow and intracranial swelling. Fluid administration guided by intracranial pressure (ICP), cerebral perfusion pressure (CPP; calculated number CPP = MAP - ICP; MAP is mean arterial pressure), arterial blood pressure, and saturation of mixed venous blood (SvO2) is critical.

ICP monitoring may be used in patients with severe head injuries who have a high probability of developing intracranial hypertension. Some physicians use a Glasgow Coma Scale score of less than 7 as an indicator for monitoring ICP. The goal of this monitoring is to maintain the ICP at less than 10 mm Hg and the CPP at greater than 80 mm Hg. Management of intracranial hypertension can also be done by draining cerebrospinal fluid through a ventriculostomy.

Some patients may have episodes of agitation and pain, which can increase ICP. Sedatives and analgesics can be administered to control intermittent increases in ICP, with a resulting decrease in CPP. Additionally, some patients with severe head injuries may require chemical paralysis to improve oxygenation and ventilation. Other complications are also managed pharmacologically, such as seizures (by anticonvulsants), increased ICP (by barbiturate coma), infection (by antibiotics), and intracranial hypertension (by diuretics).

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